Antithrombin Deficiency in Trauma and Surgical Critical Care.

Antithrombin deficiency (ATD) was described in 1965 by Olav Egeberg as the first known inherited form of thrombophilia. Today, it is understood that ATDs can be congenital or acquired, leading to qualitative, quantitative, or mixed abnormalities in antithrombin (AT). All ATDs ultimately hinder AT's ability to serve as an endogenous anticoagulant and antiinflammatory agent. As a result, ATD patients possess higher risk for thromboembolism and can develop recurrent venous and arterial thromboses. Because heparin relies on AT to augment its physiologic function, patients with ATD often exhibit profound heparin resistance. Although rare as a genetic disorder, acquired forms of ATD are seen with surprising frequency in critically ill patients. This review discusses ATD in the context of surgical critical care with specific relevance to trauma, thermal burns, cardiothoracic surgery, and sepsis.

Aggressive Crystalloid Resuscitation Outcomes in Low-Severity Pediatric Trauma.

BACKGROUND: Trauma is the leading cause of death among children. Studies have found that insufficient intravenous (IV) fluid resuscitation contributes significantly to morbidity and mortality in pediatric trauma. While large-volume resuscitation represents a potential solution, overly aggressive fluid management may complicate hospitalizations and recovery. Through this study, we aim to evaluate the impact of aggressive fluid resuscitation on outcomes in pediatric trauma. MATERIALS AND METHODS: This is a retrospective review utilizing our level I trauma center registry for pediatric patients aged <16 y admitted from 2014 to 2017. Patients transferred from our center within 24 h and those who arrived from outside hospitals were excluded. Patients who received blood product transfusions were excluded. Included patients were divided into two crystalloid groups: <60 mL/kg/24 h and ≥60 mL/kg/24 h. Outcome measures included ICU length-of-stay, length-of-hospitalization, complications, and mortality rate. RESULTS: Study sample included 320 patients (<60 mL/kg/24 h = 219; ≥60 mL/kg/24 h = 101). The ≥60 mL/kg/24 h group was younger (9.95 versus 5.27, P = 0.0001). There were no significant differences in GCS on arrival, injury severity score, Abbreviated Injury Scale, Revised Trauma Scores, traumatic brain injury, and operative intervention between groups. Outcome measures showed there was no significant difference in 30-day readmission rate, complications, or mortality. Large-volume crystalloid resuscitation was associated with longer mean ICU length-of-stay (1.5 d versus 0.8 d, P = 0.004). CONCLUSIONS: In this single-institution retrospective database analysis, large-volume crystalloid resuscitation (≥60 mL/kg) was associated with a significant increase in ICU length-of-stay without survival benefit. More research in the form of randomized trials will help determine the optimal rate for fluid resuscitation in pediatric trauma patients while weighing potential critical care complications.

Thoracic Endovascular Aortic Repair Versus Open Repair: Analysis of the National Trauma Data Bank.

BACKGROUND: Blunt thoracic aortic injuries (BTAIs) carry a substantial mortality rate. Our study aimed to compare the outcomes of thoracic endovascular aortic repair (TEVAR) with open repair from trauma centers across the United States using the National Trauma Data Bank-Research Data Set (RDS). MATERIALS AND METHODS: The National Trauma Data Bank-RDS was reviewed for thoracic aortic injures and repair methods. Patients were divided into two groups: TEVAR versus open repair. Demographics and outcomes were compared between groups. Mortality rate was adjusted using the observed/expected mortality (O/E), with TRISS methodology by using the Revised Trauma Score with the Injury Severity Score. Chi-square test and t-test were used with significance defined as P < 0.05. RESULTS: Within the 2016 RDS, there were 275 cases that underwent operative repair for BTAI. Of the 275 operative cases, 62.5% (172/275) had TEVAR and 37.5% (103/275) underwent open repair. Mean age in TEVAR group was 41 and open repair group was 36 (P > 0.05). Mean Injury Severity Score for TEVAR was 36 versus 35 for open repair (P > 0.05). Mean Revised Trauma Score was 6.7 in TEVAR versus 5.5 in open group (P > 0.05). TEVAR patients had significantly lower crude mortality rate versus open repair (11% versus 25.2%, P < 0.005). When adjusted using O/E, the TEVAR group also had significantly less deaths versus open repair (0.40 versus 0.68, P < 0.000008). CONCLUSIONS: For BTAIs, thoracic endovascular aortic repairs were superior to open repair on injury-adjusted, all-cause mortality.

Mild and Moderate Traumatic Brain Injury and Gender-Based Critical Care Outcomes.

BACKGROUND: Traumatic brain injury (TBI) is a major contributor to death and complications. Previous studies have identified gender disparities among trauma patients. This study aims to examine the association between gender and outcomes in TBI patients. STUDY DESIGN AND METHODS: Review of our trauma registry: Patients were classified into groups according to their gender. Demographics extracted from the registry included age, injury severity score (ISS), Glasgow Coma Score (GCS), head abbreviated injury score (AIS), and the presence of an epidural hematoma (EDH). The primary outcome was mortality; secondary outcomes included ICU length of stay (ICU-LOS), craniotomy rate, ventilator-associated pneumonia (VAP), and readmission rates. Significance was defined as p < 0.05. RESULTS: Nine hundred and thirty-five patients with TBI were studied: 62.1% (n = 581) were male and 37.9% (n = 354) were female. There were no differences in GCS, ISS, and head AIS. Males were younger [53 (IQR 30-77) vs. 76 (IQR 49.25-84), p < 0.05] and were more likely to have an EDH (9.6% vs. 4.8%, p = 0.007). Males also had a longer median ICU-LOS [4 days (IQR 2-8) vs. 3 days (IQR 0-5), p < 0.05] and were significantly more likely to require a craniotomy (44.6% vs. 19.2%, p < 0.001). In addition, males were more likely to develop VAP (4.1% vs. 0.8%, p = 0.004). Predicted survival (79.2% vs. 72.9%) and actual mortality rates (4.5% vs. 4.5%) were similar in both genders (p > 0.05). CONCLUSION: In the context of our study, male patients with TBI were significantly younger, were more likely to sustain an EDH, and were also more likely to require a craniotomy, but mortality rates between both genders were similar. The male gender was also associated with a significantly increased ICU-LOS and VAP.

Massive transfusion protocols in paediatric trauma population: A systematic review.

BACKGROUND: Our main objective was to review the literature to answer the following questions regarding paediatric massive transfusion (PMT) protocols: (a) How is PMT defined?; (b) Which blood product ratios have been investigated, and what is their effect on outcomes?; and (c) What evidence exists regarding PMT outcomes? METHODS: The PRISMA guidelines were used. We searched PubMed, Google Scholar, Cochrane Library, EMBASE, Wiley Online Library and Ovid. Articles were screened for inclusion based on relevance to PMT. Articles were assessed for study design, presence of established/tested PMT, PMT definition, PMT activation criteria and Transfusion Ratios for the final determination of article inclusion. RESULTS: Our search produced 3213 articles, with 33 included for final review. Existing definitions of PMT are based on volume administered/kg but vary in timeframe criteria (over 4 hours vs 24 hours). Some studies have investigated "high" balanced transfusion ratios as seen in adults (1:1 FFP:pRBC), with a few showing statistically significant improvement in paediatric mortality vs lower ratios. PMT protocol implementation has not been shown to consistently reduce paediatric trauma mortality across multiple centres. However, other operational aspects, such as reduced time to first transfusion, are apparent benefits. CONCLUSIONS: There is poor consensus over the definition of PMT. Definitions that involve early recognition have the most promise for practice and future studies. Evidence supporting an optimal blood product ratio in PMT is also lacking but trends towards supporting balanced approaches. Implementation of PMT protocols has been limited in showing significant improvement of overall paediatric trauma mortality but may reduce associated morbidity.

Massive transfusion protocol in adult trauma population.

BACKGROUND: Acute blood loss in trauma requires quick identification and action to restore circulating volume and save the patient. Massive transfusion protocols (MTPs) have become standard at Trauma Centers, in order to rapidly deliver blood products to bleeding patients. This literature review presents current standards of transfusion ratios, as well as insights into adjuncts during massive transfusions. METHODS: PubMED was searched for articles from 2005 to 2020 on MTPs, the article were assessed for single vs. multi-institutional, mechanism of injury, type of MTP, timing in which blood products should be administered, timing of delivery of blood products to trauma bay, pre-hospital treatment and adjuncts, and outcomes. RESULTS: Eleven studies addressed transfusion ratios. Seven studies looked at timing of blood products. Nine studies addressed MTP pre-hospital treatment and adjuncts. Prior to 2015, studies supported the benefits of a balanced transfusion ratio, which was then confirmed by the PROPPR randomized controlled trial. The shorter the time to blood product delivery the better the outcomes. New advances in technology have allowed us to measure different patterns of coagulation, allowing more individualized approaches to the bleeding patient. CONCLUSION: Current massive transfusion protocols should utilize between 1:1:1 and 1:1:2 ratios of the 3 main products; plasma, platelets, and red blood cells. Massive transfusion protocols are effective in decreasing mortality. Better resuscitation efforts were seen when blood products were readily available in the trauma bay when the patient arrived and the faster the replacement of blood, the better the outcomes.

SARS-CoV-2 pharmacologic therapies and their safety/effectiveness according to level of evidence.

INTRODUCTION: There is a pressing need for COVID-19 transmission control and effective treatments. We aim to evaluate the safety and effectiveness of SARS-CoV-2 pharmacologic therapies as of August 2, 2020 according to study level of evidence. METHODS: PubMed, ScienceDirect, Cochrane Library, JAMA Network and PNAS were searched. The following keywords were used: ((COVID-19) OR (SARS-CoV-2)) AND ((((((therapeutics) OR (treatment)) OR (vaccine)) OR (hydroxychloroquine)) OR (antiviral)) OR (prognosis)). Results included peer-reviewed studies published in English. RESULTS: 15 peer-reviewed articles met study inclusion criteria, of which 14 were RCTs and one was a systematic review with meta-analysis. The following pharmacologic therapies were evaluated: chloroquine (CQ), hydroxychloroquine (HCQ), antivirals therapies, plasma therapy, anti-inflammatories, and a vaccine. CONCLUSION: According to level 1 evidence reviewed here, the most effective SARS-Co-V-2 pharmacologic treatments include remdesivir for mild to severe disease, and a triple regimen therapy consisting of lopinavir-ritonavir, ribavirin and interferon beta-1b for mild to moderate disease. Also, dexamethasone significantly reduced mortality in those requiring respiratory support. However, there is still a great need for detailed level 1 evidence on pharmacologic therapies.

Elderly Patients With Isolated Hip Fracture Requiring Surgical Intervention: Does Admitting Service Matter?

The American College of Surgeons requires trauma centers to track the number of injured patients admitted to a surgical service as well as nonsurgical admissions (NSAs) as a quality marker. We aim to compare the relationship between admitting service and outcomes in patients with isolated hip fracture (IHF). A 4-year retrospective cohort review of data collected from a single institution's trauma registry for adult patients with IHF was done. Patients were stratified into 2 groups based on admission to a surgical service versus NSA. Demographic and outcome variables including age, gender, Injury Severity Score (ISS), intensive care unit length of stay (ICU-LOS), deep venous thrombosis (DVT), and mortality rates were compared. Analysis of variance and χ test were used for data analysis with statistical significance defined as p < .05. A total of 629 patients with IHF were admitted. Of those, 30 (4.8%) were admitted to a surgical service and 599 (95.2%) were NSAs. Patients admitted to a surgical service were younger but average ISS was similar in both groups. Those admitted to a surgical service had a significantly shorter ICU-LOS than NSA patients (2.97 days vs. 4.91, p < .001). Readmission rate at 30 days (3.3% vs. 1.2%, p > .05) and DVT rates (0% vs. 0.4%, p > .05) were similar between groups. Mortality rates did not differ between groups (3.3% vs. 2.2%, p > .05). Patients with hip fracture requiring surgical intervention admitted to a trauma service have a shorter ICU-LOS than those admitted to nonsurgical services. Other quality markers were similar.

A Multidisciplinary Approach to Improve Pain Management and Satisfaction in a Trauma Population.

An adult trauma center identified pain management as a potential area for improvement. Pain management is at the height of discussion in medical centers across the United States. The Hospital Consumer Assessment of Healthcare Provider and System (HCAHPS) scores relating to pain management were consistently low (<5th percentile). This project was designed to use a collaborative and systematic approach to pain management to improve HCAHPS pain management scores. This is an evaluation of a quality improvement project using a before-and-after design with historical control. Using HCAHPS data to evaluate patients' pain management perceptions, an integrative three-pronged approach was developed and implemented: (1) development of a trauma nurse leadership program, (2) collaboration with pain management providers, and (3) modifications made to the trauma admission order set. Trauma nurse leaders educated patients and families regarding pain management goals and expectations utilizing a standardized script. HCAHPS survey data obtained before and after the intervention showed a significant improvement in patient satisfaction. HCAHPS scores on the three pain questions prior to intervention in Quarters 2 and 3 (Q2-3) 2017 had a mean of less than the 5th percentile. After intervention, HCAHPS scores on the three pain questions improved to a mean of more than the 60th percentile on Q4 2018. Implementation of a pain management strategy involving a three-pronged approach of a dedicated trauma nurse leadership program, collaboration with a pain management team, and evaluation and modification of a trauma admission order set was associated with an improvement in communication about pain with the trauma patients and HCAHPS pain satisfaction scores.

The association between seatbelt use and trauma outcomes: Does body mass index matter?

BACKGROUND: National Highway Traffic Safety Administration (NHTSA) reports that seat belt use results in a significant decrease in MVC mortality. The rate of obesity is currently extensive. There is limited data on the impact of seat belt use and body mass index (BMI) on mortality and trauma outcomes following MVCs. This study aimed to evaluate the impact of seat belt use and BMI on outcomes in adult trauma patients. METHODS: A four-year review using our Level I Trauma Center registry. Patients were divided by BMI into normal weight BMI < 25 (NL-BMI), overweight BMI 25-29.9, and obese BMI ≥ 30. Groupings were subdivided by seat belt use into patients wearing a seat belt at the time of injury (seatbeltPOS) and those who were not (seatbeltNEG). RESULTS: 11,792 patients involved in MVCs were included in our study. 4515 (38.3%) were NL-BMI, 4583 (38.9%) were overweight, and 2694 (22.8%) were obese. SeatbeltPOS patients had significantly lower mortality compared to seatbeltNEG, regardless of BMI, with 12/1394 (0.86%) in seatbeltPOS compared to 274/10,398 (2.64%) deaths in seatbeltNEG patients (p ≪ 0.001). Evaluated by BMI, overweight and obese seatbeltPOS patients had significantly less deaths 7/900 (0.78%) vs overweight and obese seatbeltNEG patients 179/6377 (2.81%) (p = 0.0004). NL-BMI seatbeltPOS patients also had significantly lower mortality 5/494 (1.01%) compared to NL-BMI seatbeltNEG patients 95/4021 (2.36%), (p = 0.048). CONCLUSION: Use of a seat belt reduced Trauma Center mortality regardless of BMI. Seat belts should be used by all patients as a mechanism to significantly reduce mortality.

Survival of trauma patients needing CPR shortly after arrival: The NationalTrauma Data Bank Research Data Set.

BACKGROUND: Cardio Pulmonary Resuscitation (CPR) for traumatized patients in the field portends poor survival but the outcome of trauma patients who arrive in-extremis and undergo CPR shortly after arrival has not been well studied. The purpose of our review is to evaluate survival to discharge for trauma patients with CPR from 1 to 120 minutes (min) after arrival. METHODS: The NTDB Research Data Set (RDS) was reviewed. Patients with vitals in the field who underwent CPR from 1 to 120 min after arrival were divided according to injury type and Injury Severity Score (ISS). Survival to discharge outcomes were determined in patients that underwent CPR from 1-60 min and 61-120 min after arrival. RESULTS: The RDS contained 968,665 patients and 9,365 (0.96%) had CPR from 1 to 120 min after arrival. For blunt injuries with CPR from 1 to 60 min, survival was similar for all levels of ISS (8.5-10.2%, p > 0.05). Blunt injury patients with CPR 61-120 min and ISS 1-15 had significantly higher survival rate compared to ISS >25 (36.1% vs 8.7%, p < 0.00003). For penetrating injuries and CPR from 1 to 60 min, survival was similar for all levels of ISS (4.3-6.8%, p > 0.05); Blunt and penetrating patients with CPR from 61 to 120 min, and ISS 1-15 had the highest survivals at 36.1 and 36.4%. CONCLUSION: Trauma patients who undergo CPR shortly after arrival have a survival rate of (4.3%-36.4%). Over one-third of blunt and penetrating injuries and low ISS who had CPR from 61 to 120 min after arrival survived. Trauma patients who arrest shortly after arrival warrant an aggressive approach.

Targeting Catheter-Associated Urinary Tract Infections in a Trauma Population: A 5-S Bundle Preventive Approach.

Complications from catheter-associated urinary tract infections (CAUTIs) can cause morbidity and mortality. Our institution's Trauma Quality and Improvement Program analysis identified CAUTIs as an outlier complication in our trauma population. This study aimed to determine whether implemented measures would reduce CAUTI rates in trauma population. A 5-S CAUTI bundle was implemented. Its effects were measured on a prospectively collected dataset of adult trauma patients using our Trauma Registry during the 4-year study period. Implemented measures included (1) staff education, (2) bladder catheter stabilization, (3) patient and caregiver education, (4) keeping the collection bag below the bladder and above the floor, and (5) daily evaluations for discontinuation. Chi-squared and t-test analyses were used with significance defined as p < .05. Twelve thousand nine hundred and sixty-two trauma patients were admitted to trauma service during the 4-year study period. Of these, 94 developed CAUTIs, with an average age of 67 years and 56% were females. The average injury severity score was 16 in patients with CAUTIs compared with 9 in non-CAUTI patients (p < .0002). In the index year, CAUTIs occurred in 41 out of 3,054 (1.34%), the following year there were 34 out of 3,455 (0.98%), in 2016 there were 11 out of 3,246 (0.33%), and 8 out of 3,207 (0.25%) in 2017 (p < .001). Results demonstrated an 80% reduction in CAUTI rate. Execution of the 5-S CAUTI bundle resulted in a significant 80% reduction in CAUTI rate in our trauma population.

Gender Distribution & Rank of Authorship in Surgical Literature.

BACKGROUND: Authorship of surgical literature is important for the career advancement of surgeons, and gender disparities in authorship may hinder the representation and leadership of women within academic surgery. The aim of this systematic review and meta-analysis was to evaluate the gender distribution of first, senior, and overall authorship in peer-reviewed surgical journal studies across all surgical specialties to determine if disparities exist. METHODS: PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the gender distribution of authorship of surgical literature published before December 10th, 2021. Meta-analysis was performed and Cohen's Q test for heterogenous effects was used to determine whether random or fixed-effects models were appropriate. RESULTS: Fifteen studies investigating gender distribution of authorship met inclusion, which included a total of 136,627 pooled studies. The meta-analysis demonstrated the meta-proportion of first authorship for women to be 20.6% (95% CI: 13.9, 28.2), the meta-proportion of senior authorship for women to be 11.9% (95% CI: 6.6, 18.5), and the meta-proportion of overall authorship for women to be 23% (95% CI: 16.2, 30.7). In addition, the proportion of senior authorship for women was found to be significantly lower than the proportion of overall authorship for women (11.9% versus 23.0%, P = .0106). CONCLUSION: There is a significantly smaller proportion of women who are first, senior, and overall authors in surgical literature compared to their colleagues who are men. Sustainable and effective solutions aimed at improving the representation of women surgeons in surgical research and research leadership are necessary.

A rare case of delayed splenic rupture following initial negative CT scan imaging: A case report and review of the literature.

INTRODUCTION: Delayed splenic rupture is an often unpredictable event with high mortality. In this report, we discuss the successful management of delayed splenic rupture, presenting days after index injury, with no commonly associated injuries or blunt abdominal trauma. CASE PRESENTATION: A 50 year old male, not on anticoagulants, presented with blunt trauma after driving his motorcycle into a tree. The patient sustained right 3-5 rib fractures, displaced right midclavicular fracture, 25 % right pneumothorax, T5-9 posterior spinous process fractures, left 2nd-5th metatarsal fractures, and scattered abrasions to the left foot, knee and hand. Focused abdominal sonography for trauma (FAST) and admission abdominal multi-detector CT were negative for any intra-abdominal injuries. On hospital day 5, the patient acutely decompensated. FAST was grossly positive and emergent laparotomy revealed a splenic rupture. After a splenectomy, he recovered. DISCUSSION: The spleen is the most commonly injured organ in blunt abdominal trauma. Although acute injury often presents with imaging findings or sequelae of hemorrhagic shock, complications of splenic trauma have the potential to result in delayed catastrophe. Bedside ultrasonography is a useful tool to assess acute decompensation in trauma patients along with CT imaging. Prompt identification and hemorrhage control are crucial to survival after trauma. CONCLUSION: Repeat CT scans are also important for the identification of delayed splenic rupture and timely intervention. Delayed hemorrhage after blunt trauma should never be ruled out regardless of the injury complexity or length of hospital admission.

Survival following devastating penetrating gunshots polytrauma with grade 5 liver injuries requiring multiple massive transfusion protocols: A case report and review of the literature.

INTRODUCTION: A devastating injury to the liver from a gunshot wound (GSW) challenges the most seasoned trauma surgeon. This challenge is intensified when patients develop severe shock with a high-grade injury. We present the case of a patient with a grade 5 liver injury after a GSW treated with operative and interventional radiology (IR) treatment simultaneously. CASE PRESENTATION: A 25-year-old male presented to our Trauma Center with hypotension, after an abdominal GSW. He was taken emergently to the operating room, which revealed a Grade 5 liver injury with massive hemorrhage. Operative intervention was initiated immediately and a non-anatomic left lobectomy with hepatorrhaphy was performed. IR was consulted intra-operatively and performed a left hepatic artery angioembolization. The patient received over 50 units of blood products during the combined procedures, with eventual bleeding control. On post-operative day 33, the patient became acutely hemodynamically unstable, and angiography revealed a splenic artery pseudoaneurysm, which was embolized but re-bled and resulted in splenectomy. The patient eventually recovered and follows up at 1-year revealed a patient doing well. DISCUSSION: High-grade liver injuries carry significant mortality. Mortality worsens when severe shock is present. Operative intervention is the standard approach for patients who remain in shock. To help improve outcomes patients may benefit from a combined approach with the interventional radiology team. CONCLUSION: The acute management of severe liver injuries when presenting with ongoing shock is beneficial to include both trauma surgeons with interventional radiologists. Further studies are needed to determine the best approach for this devastating injury.

SARS-CoV-2 vaccine candidates: A beginning of the end of COVID-19 pandemic- Editorial.

•All three vaccines have substantial efficacy in preventing symptomatic and severe Sars-CoV-2 infection.•Vaccine dissemination is important due to the rapid mutagenic nature of the virus and continuing decline in the health and economies around the world.•Further attempts to achieve widespread access of the vaccine is vital for all preventative measures to be maximally successful.